EMS Helicopter Fuel Exhaustion

Could texting distraction have led to a series of disastrous mistakes?

As you may have heard by now, the NTSB has asked the FAA to prohibit the use of portable electronic devices (PED) — read smart phones, tablets, etc. — for non operational use by crewmembers at their flight deck duty stations while the aircraft is being operated. This would include FAR Part 135 and 91 Subpart K operations.

The Safety Board also wants Part 121, 135 and 91 Subpart K operators to incorporate into their initial and recurrent pilot training programs and manuals “information on the detrimental effects that distraction due to the nonoperational use of PEDs can have on performance of safety-critical ground and flight operations.”

The latest series of PED recommendations arises from the Safety Board's investigation into the loss of a Eurocopter AS350 B2 helicopter that crashed on Aug. 26, 2011, in Mosby, Mo., killing all on board — the pilot, flight nurse, flight paramedic and patient. Air Methods, doing business as LifeNet in the Heartland, operated the helicopter.

Essentially, the helicopter flew three legs in daylight VFR conditions, ran out of fuel and then crashed at the bottom of a mismanaged autorotation. The Safety Board determined the probable causes were: the pilot's failure to confirm that the helicopter had adequate fuel on board to complete the mission before making the first departure, his improper decision to continue the mission and make a second departure after he became aware of a critically low fuel level, and his failure to successfully enter an autorotation when the engine lost power due to fuel exhaustion.

Contributing to the accident, said the Safety Board, were (1) the pilot's distracted attention due to personal texting during safety-critical ground and flight operations, (2) his degraded performance due to fatigue, (3) the operator's lack of a policy requiring that a [company] operational control center specialist be notified of abnormal fuel situations and (4) the lack of practice representative of an actual engine failure at cruise airspeed in the pilot's autorotation training in the accident make and model helicopter.

While the NTSB has been chasing the PED demon for quite a while, the other identified contributing factors may be more important. Arguably, PEDs can be a distraction; but fatigue, misunderstanding of critical performance factors and inexact training may have more relevancy in the greater scheme of helicopter safety.

The Accident

The helicopter was based at Rosecrans Memorial Airport (STJ), St. Joseph, Mo. When used for EMS flights, the AS350 was equipped with one pilot seat and a single set of controls along with a medical interior kit to accommodate one patient and two medical attendants. During the week before the accident flight, the accident AS350 was reconfigured to conduct night vision goggle (NVG) pilot training. The medical interior had been removed and the copilot's seat and controls installed. While the accident helicopter (N352LN) was used for training, the St Joseph base used another Air Methods Eurocopter AS350 (N101LN) for EMS flights.

The last NVG training flight in N352LN was completed about 0300 on the day of the accident. The NVG instructor told investigators he did not have the helicopter refueled because the EMS pilot coming on duty needed to determine the amount of fuel required after the helicopter had been returned to service in EMS configuration. The EMS duty helicopter was typically loaded with a 70% fuel load that provided about 2 hr. flight time.

The 35-year-old, U.S. Army-trained accident pilot reported for duty on Aug. 26 at 0630, about an hour after he woke up at his layover hotel. The departing night shift pilot briefed the accident pilot on the status of the active helicopter (N101LN) and the status of the accident helicopter (N352LN). Eurocopter N101LN would remain the active EMS helicopter until N362LN was reconfigured. The lead pilot also told the accident pilot that N352LN would have to be refueled once the mechanic completed the changeover.

The accident pilot conducted a preflight inspection of N101LN and signed its daily flight log as required by the Air Methods General Operations Manual (GOM). The helicopter mechanic began to reconfigure the accident helicopter for EMS work at 0700. About 1400, the mechanic told the accident pilot that the reconfiguration work was complete, and together they performed a walk-around inspection so the mechanic could show the pilot what had been done.

Once the walk-around was finished, the flight nurse and flight paramedic prepared the cabin for duty while the pilot transferred his gear and paperwork from the active helicopter to the accident helicopter. The crew had completed the transfer by 1530.

Company procedures required that the pilot perform a preflight inspection including a fuel quantity check before it was returned to service. Examination of the helicopter's daily flight log revealed that the pilot did not sign it as required by the GOM to indicate that he had completed the preflight inspection. The pilot failed to take fuel samples as required by the GOM. The mechanic had made three “conform your aircraft” (CYA) entries in the maintenance log after the reconfiguration operation, but the pilot did not initial the CYA entries as also required by the GOM.

The Air Methods Communication Center (AirCom) received a request at 1719 to transport a patient from Harrison County Community Hospital in Bethany to Liberty Hospital in Liberty, both in Missouri. AirCom notified the pilot at 1720. The pilot accepted the flight.

The helicopter departed about 1728. Two minutes later, the pilot reported by radio to the AirCom communications specialist that the helicopter had departed STJ with 2 hr. of fuel and three persons on board. Thirty minutes later, the helicopter landed at the Harrison County Community Hospital helipad to pick up the patient.

The flight nurse and flight paramedic took their stretcher to the hospital's emergency room to prepare the patient for flight. The pilot stayed in the helicopter and, about 1759, contacted AirCom using his company-provided cell phone. He told the communications specialist that he had realized about halfway through the flight from STJ that the helicopter did not have as much fuel on board as he originally thought. The pilot said he had mistakenly reported the fuel from N101LN, not from the accident helicopter, and that he would have to stop somewhere and obtain fuel.

The communication specialist asked the pilot if he could make it to Liberty Hospital, some 62 nm distant with an estimated time en route of about 34 min. The pilot answered, “That's going to be cutting it pretty close. I'm probably going to need to get fuel before that.”

The communications specialist and pilot determined the only airport with Jet-A fuel along the route of flight to Liberty Hospital was Midwest National Air Center (GPH) in Mosby, about 58 nm away from Harrison and just 4 mi. short of Liberty Hospital. The pilot said, “Fifty-eight nautical miles. So it would save me, save me 4 nm and 2 min. I think that's probably where I'm going to end up going.”

The pilot said he would refuel at GPH with the patient on board. “I don't want to run short and I don't want to run into that 20-min. reserve if I don't have to . . . We'll take off. I'll see how much gas I have when I go and I'll call you when we're in the air.”

Neither the pilot nor the busy communication specialist discussed contacting the Air Methods Operational Control Center (OCC) to inform the OCC of the low fuel situation or the changed flight route. (The NTSB believes operational specialists might have overridden the pilot's decision to depart Harrison County.)

Minutes later, the flight nurse and flight paramedic arrived back at the helicopter and loaded the patient into the helicopter. At 1811, the helicopter lifted off and the pilot reported via radio to AirCom that he had 45 min. of fuel and four persons on board and was en route to GPH. About 1813, the pilot requested that AirCom contact the FBO at GPH to indicate that the helicopter was inbound for fuel, and that was done.

At 1815, the AirCom communication specialist notified the AirCom supervisor that the helicopter was low on fuel and would be refueling with the patient on board at GPH. About 1827, AirCom notified the pilot via radio that the fuel arrangement had been made at GPH. The pilot acknowledged the radio transmission. It was the last recorded transmission from the pilot.

The helicopter headed directly toward GPH cruising between 400 and 600 ft. AGL with an average ground speed of 111 to 116 kt. At 1841, the last satellite tracking system position recorded was about 0.9 nm from the accident site and showed the helicopter was at 373 ft. AGL with a 116-kt. ground speed. When the pilot did not report arriving at GPH, AirCom called the FBO, and the wreckage was located shortly thereafter in a farm field about 1 nm from the approach end of Runway 18 at GPH. There were no witnesses to the accident.

The aircraft structure was heavily fragmented and scattered along a 100-ft.-long debris path. No one had survived. The damage to the rotor blades was consistent with a low rotor rpm at impact. Initial impact was about 40-deg. nose-low at high speed. There was no post-impact fire. Indeed, no fuel was located at the accident site other than a liter or so in the fuel system plumbing. The evidence was consistent with a loss of engine power due to fuel exhaustion. Engine manufacturer metallurgic studies suggest impact must have occurred within the first 10 sec. after flameout.

Human Factors

The pilot held a commercial certificate with rotorcraft-helicopter and instrument-helicopter ratings. His second-class medical certificate had no limitations. He joined Air Methods in September 2010 after serving in the Army as Boeing AH-64 Apache helicopter PIC, but had no previous civil commercial flight experience.

His total rotorcraft flight time was about 2,207 hr. He flew 18 hr. within the 30 days before the accident and 74 hr. within the previous 90 days. The pilot had accumulated a total of 104 flight hours in the Eurocopter AS350 B2 and 32 flight hours in the Eurocopter AS350 B3 between Oct. 10, 2010, and Aug. 26, 2011.

The pilot started his basic indoctrination training with Air Methods on Sept. 13, 2010. After receiving 4.2 hr. of flight training, on Oct. 6, 2010, he satisfactorily completed an initial flight evaluation. The check included power failures, autorotations to a power recovery (but without a reduction in power) and hovering autorotations (oral only).

Fatigue

The pilot had been off duty for five days before the accident — most of that time at home in Lincoln, Neb. The day before the accident, the pilot checked into the layover hotel in St. Joseph about 1423 and attended a company ground training session at 1630. The pilot's wife spoke with him later that evening and he had “sounded good.” A coworker (an Air Methods communication specialist) also spoke with the pilot by telephone that evening and reported that the pilot stated his training went well. He used his cell phone at about 1123 and again at 0019 on the morning of the accident.

On Aug. 26, the day of the accident, the pilot arrived for his shift sometime before 0630. He spent 20 min. discussing operations with the departing night-shift pilot who recalled later that the accident pilot seemed alert. Coworkers all described him as alert and functioning normally; however, the accident pilot told a coworker during a telephone call at 0830 that he did not sleep well in the hotel and felt tired.

According to cell phone records, the pilot made and received multiple personal calls and text messages throughout the day. The Safety Board correlated cell phone voice and texting records with the day's activities. During the period that the pilot was checking the reconfiguration of the accident aircraft, the pilot received multiple text messages and responded to some. Additional text messages were sent from the pilot's cell phone during time periods when the helicopter was in flight on the accident leg and the preceding leg and while the helicopter was on the Harrison County Community Hospital helipad.

Safety Board’s Analysis

The Safety Board believes the pilot missed three discrete opportunities to identify that the helicopter had inadequate fuel to complete the assigned mission — (1) during a required preflight inspection, (2) immediately before takeoff and (3) during the post-takeoff status report to AirCom. The electric fuel gauge was operating correctly and should have accurately displayed the helicopter's fuel state, about half of the normal 2-hr. fuel load, at these times.

It is unlikely, said the Safety Board, that the pilot deliberately misreported the fuel level because Jet-A fuel was available at the takeoff airport, and the pilot could have had fuel added without difficulty or penalty. It also seems unlikely that the pilot repeatedly misread the gauge indication, especially given the obvious difference in visual indication between the actual level (35%) and the reported level (70%).

Although the pilot had been advised during the shift change briefing that the helicopter was low on fuel, said the Safety Board, it is possible he forgot about this communication during the intervening 11 hr. before the first leg of the mission. If so, he might reasonably have expected the normal 70% level for an active helicopter.

“Such an expectation would be consistent with the incorrect fuel status report he provided after takeoff. Also, consistent with what the pilot subsequently stated, he had performed a preflight inspection on the earlier active helicopter (N101LN), and it was fueled to 70%.” Past Safety Board investigations have identified instances in which pilots made callouts without first verifying the cockpit indication that corresponded with the callout. Therefore, it is likely in this case that the pilot reported the fuel he expected to be in the helicopter without effectively referencing the fuel gauge.

The pilot's plan to proceed from Harrison to Liberty “was highly risky because of the limited fuel on board, said the Board. The plan did not meet 20-min. reserve fuel requirements for Part 135 operations. The difference between the actual fuel situation (30 min. or about 18%) and the fuel the pilot reported in his post-takeoff report (45 min. or about 26%) corresponded to a difference of about one marked increment on the fuel quantity gauge and should have been apparent to the pilot as he waited on the ground and considered his abnormal fuel situation. Further, the difference between the actual fuel situation and the minimum fuel required for the trip (52 min. based on the estimated time en route to GPH of 32 min.) was even greater. “Therefore, the pilot almost certainly knew that he did not have the required fuel reserve and misrepresented his fuel situation in his post-takeoff report because he wanted to give the appearance of compliance with the 20-min. fuel reserve requirement.”

The pilot undoubtedly knew that his decision to proceed with the mission was risky, and company personnel uniformly reported that the pilot could have aborted the mission at Harrison County Community Hospital without fear of serious negative consequences from the company, said the Safety Board. “This raises questions about the reasons for the pilot's decision to proceed. The pilot was new to the company and might have been concerned that aborting the mission as a result of an error during preflight preparation would negatively affect others' perceptions of his reliability as an employee. In addition, aborting the mission would likely have involved inconveniences (such as waiting at the hospital for fuel to be delivered) that the pilot probably preferred to avoid. Finally, he might have been influenced by time pressure associated with the urgency of the patient's medical condition and the implications of a delay in treatment. “Although the pilot did not express such concerns during any recorded communication, such concerns have played [roles] in past safety-related incidents involving EMS flights. At the very least, the pilot would have expected that aborting the mission would result in some degree of discomfort for him and the patient. The NTSB concludes that the pilot departed on the second leg of the mission despite knowing that the helicopter had insufficient fuel reserves likely in order to avoid delays and other possible negative outcomes that could have resulted from aborting the mission.”

During the accident flight, the pilot was likely monitoring the fuel gauge closely and watching the fuel level decrease. As he approached GPH, the indicated fuel level would have approached zero. This might have prompted the pilot to consider landing the helicopter somewhere off-airport as a precautionary measure, said the Safety Board, “however, by the time the fuel gauge was near zero, the airport was in sight and the pilot was very close to successfully concluding the flight, and he may have been reluctant to land because it would have revealed his noncompliance with the 20-min. fuel reserve requirement. The pilot's decision to continue the flight rather than make a precautionary landing, despite mounting evidence that fuel exhaustion was imminent, was a decision error.”

The Safety Board stressed that there is no evidence that the pilot performance deficiencies were common in company operations or consistent with company policy. Rather, the company had formal operational procedures, including the completion of a preflight inspection and use of the before-takeoff checklist that, if complied with, would have led the pilot to detect the helicopter's low fuel level before departing on the first leg of the mission.

Texting Distractions?

Personal issues in the pilot's life might have been a source of distraction, said investigators. His wife was pregnant with their first child, his father recently had undergone cardiac surgery, and he had moved recently to a new city but was still commuting to his old base in St. Joseph. In addition, on the day of the accident, he was making social plans to meet his coworker for dinner after his work shift. “During his shift, the pilot needed to focus his attention away from personal issues when performing safety-related tasks, but at such times, both before departure and during the mission, he engaged in personal texting activities.”

The NTSB examined the pilot's personal cell phone records to see whether distraction caused by the pilot's personal electronic communications could have played a role in his incomplete preflight inspection. The pilot received frequent text messages between 1406 and 1455 — a substantial portion of the time period when the helicopter was being prepared for its return to service. However, the pilot only responded to these texts between 1430 and 1450. Therefore, personal electronic communications did not necessarily preclude the performance of a complete preflight inspection, but they could have distracted the pilot.

The change in helicopters caused a break in routine that could also have played a role in the pilot's incomplete preflight inspection. The disruption caused by the change-out would have required the pilot to think purposefully about the actions that he needed to accomplish, and periodic interruptions of his attention caused by text messaging activity could have resulted in his forgetting about tasks that he had not yet completed. Moreover, the effect of such interruptions on the pilot's memory could have been exacerbated by fatigue.

“In this accident, the pilot engaged in nonoperational use of his personal cell phone when the helicopter was being prepared for return to service,” said the Safety Board. “Although this activity did not prevent the performance of a thorough preflight inspection, it was a source of distraction that increased the risk of lapses of attention and errors of omission, which did, in fact, occur. Therefore, it is possible that the pilot's nonoperational use of a portable electronic device contributed to his lack of awareness of the helicopter's abnormally low fuel state.”

Company procedures prohibited pilots from using or turning on cell phones during active flight operations. The overlay of the pilot's personal cell phone records, however, indicates that he sent one text message during the first leg of the mission and three during the accident flight. All of these inflight messages were sent after the pilot became aware of the helicopter's low fuel state. The last outgoing text was sent about 20 min. before the accident, and the pilot did not respond to two incoming text messages sent 15 and 11 min. before the accident.

The Safety Board found no evidence that the pilot's airborne texting activities directly affected his response to the engine failure. “However, the personal texting activities would have periodically diverted the pilot's attention from flight operations and aeronautical decision-making. At a minimum, the pilot's attention would be diverted for the amount of time it took to read and compose messages. Further, from a control usage standpoint, to send a text, the pilot would require at least one hand to be temporarily removed from active control of the helicopter.”

The Safety Board said the pilot exchanged an additional three text messages while he was on the ground between flights waiting for the patient to be loaded into the helicopter. The pilot was working with the communication specialist during this period to address the abnormal low fuel situation and needed to make a critical launch decision. “Careful attention and conscientious problem solving were needed and should have led him to seek additional operational guidance from the company and to reject the launch due to insufficient fuel. Instead, he devoted a portion of the available time to personal texting.”

The Board concluded, “. . . the pilot's personal texting activities likely degraded his decision-making performance when he decided to continue the mission. The pilot's texting, which occurred (1) while flying, (2) while the helicopter was being prepared for return to service and (3) during his telephone call to the communication specialist when making his decision to continue the mission, was a self-induced distraction that took his attention away from his primary responsibility to ensure safe flight operations. Further, although there is no evidence that the pilot was texting at the time of the engine failure, his texting while airborne violated the company's cell phone use policy.”

Following the accident, Air Methods modified its policy on the use of cell phones. The new policy states, in part, the following:

“In compliance with FAA regulations and to prevent distractions, the PIC shall not allow cellular phones/portable electronic devices to be used or turned on during ground operations including taxi and hover operations, takeoff, en route, approach and landing. . . . In the interest of safety, this is a zero tolerance policy.”

Autorotation Guidance

The pilot's awareness of the helicopter's low fuel status and the near zero indication on the fuel gauge as the flight continued should have given him ample warning of the impending engine failure and provided him with the opportunity to prepare to execute an autorotation. Apparently, that didn't happen.

Simulator flight evaluations conducted during the investigation demonstrated that it was possible to maintain rotor rpm and execute a successful autorotation from low-level cruise flight with touchdown occurring about 25 sec. after engine failure. However, a successful autorotation was only possible if simultaneous flight control inputs of down collective and aft cyclic were made within about 1 to 2 sec. after the engine failure. If these flight control inputs were not promptly made, the result was a rapid decay in rotor rpm and impact with terrain in a nose-down attitude in an average time of 4 to 5 sec. after the simulated engine failure.

The pilot was required to demonstrate competency in performing autorotations during his Part 135 initial and recurrent training. The practice autorotations that Air Methods pilots performed were done at airspeeds of about 80 kt. This was consistent with traditional flight training for autorotations that is typically done at airspeeds below cruise and emphasizes immediate lowering of the collective as the first pilot action in response to a loss of engine power. However, Eurocopter AS350 B1 certification flight test data suggest that following a simulated engine failure at cruise speeds comparable to the accident scenario, the pilot may need to make a substantial aft cyclic input within 1.5 sec. of engine failure to achieve a successful autorotation entry.

The simulator flight evaluations also showed that the helicopter tended to pitch down rapidly following a simulated engine failure at 115 kt., requiring immediate use of aft cyclic to enter the autorotation and avoid an unrecoverable decay in rotor rpm. Pilots might not be able to initiate the appropriate flight control inputs (aggressive aft cyclic, down collective and left antitorque pedal) within such a short period of time unless they have received extensive practice in similar flight conditions. “Thus, the pilot's autorotation training was not representative of an actual engine failure at cruise speed and did not optimally prepare him to respond appropriately to such a scenario,” said the Safety Board.

When the pilot received his training in the Eurocopter AS350 B2, the Air Methods AS350 Flight Training Maneuvers Manual listed “smooth, positive reduction” of the collective to the full down position as the first step in performing a practice autorotation. This was consistent with the emergency procedure in the AS350 B2 RFM and with the general guidance provided by the FAA in the Helicopter Flying Handbook and the Helicopter Instructor's Handbook.

Following the accident, Air Methods changed the guidance on autorotations in its Eurocopter AS350 pilot training program to emphasize the importance of applying simultaneous control inputs when entering an autorotation. “It is imperative that the pilot take immediate action to change to an autorotative attitude; i.e., simultaneously applying aft cyclic, lowering the collective to maintain rotor rpm and trimming the aircraft. Failure to apply aft cyclic while lowering the collective will result in a nose-low attitude; this condition may be unrecoverable at low altitudes.”

The Safety Board says it recognizes that the motions of a helicopter following an engine power loss vary greatly from one make and model helicopter to another and from one flight condition to the next. Therefore, the technique required for safely entering an autorotation will vary, and there is no technique of universal applicability. However, in discussions with experienced helicopter flight instructors and test pilots, NTSB investigators found agreement that simultaneous control inputs, as opposed to only lowering the collective, should be used when entering an autorotation and that the critical task when entering an autorotation is to establish airflow upward through the main rotor system. The instructors and test pilots interviewed reported that the Eurocopter AS350 B2 is not unique in requiring simultaneous application of aft cyclic and down collective to safely enter an autorotation at cruise airspeeds; rather this technique is applicable to many, if not all, helicopters with low-inertia rotor systems.

The Safety Board believes that the additional information about autorotation entries provided by Air Methods to its AS350 pilots would be equally valuable to all pilots flying helicopters with low-inertia rotor systems. Therefore, the Board recommended that the FAA inform pilots of helicopters with low-inertia rotor systems about the circumstances of this accident, particularly emphasizing the findings of the simulator flight evaluations, and advise them of the importance of simultaneously applying aft cyclic and down collective to achieve a successful autorotation entry at cruise airspeeds.

The NTSB's review of the guidance on performing autorotations in the FAA's Helicopter Flying Handbook — the primary source of information on helicopter aerodynamics and flight maneuvers published by the FAA — found that it emphasizes lowering the collective as the initial step in entering an autorotation, does not address the use of simultaneous control inputs in response to an engine failure, and contains minimal information on the entry phase of autorotations. Therefore, the Safety Board recommended that the FAA revise the Helicopter Flying Handbook to include a discussion of the entry phase of autorotations that explains the factors affecting rotor rpm decay and informs pilots that immediate and simultaneous control inputs may be required to enter an autorotation.

Air Methods is now providing all of its Eurocopter AS350 pilots with autorotation training and line-oriented flight training in a full-motion Eurocopter AS350 flight simulator. The NTSB believes that use of a flight simulator addresses the lack of practice representative of an actual engine failure at cruise airspeed in the accident pilot's autorotation training because engine failures in a simulator are representative of an actual engine flameout and can be induced unexpectedly in any flight condition.

This accident highlights the value of using simulators and flight training devices (FTD) for helicopter pilot training.

Bottom Line

The Safety Board, through the work of its investigators and consultants, reached these conclusions among others:

Although the helicopter's low fuel state was clearly indicated, the pilot missed three opportunities to detect the condition: (1) before departing on the first leg of the mission as a result of his inadequate preflight inspection, (2) before takeoff by failing to properly complete the before-takeoff confirmation checklist and (3) after takeoff when he erroneously reported the fuel level.

The pilot departed on the second leg of the mission despite knowing that the helicopter had insufficient fuel reserves likely in order to avoid delays and other possible negative outcomes that could have resulted from aborting the mission.

Self-induced pressure likely caused the pilot to fixate on his intended refueling point and continue the flight rather than make a precautionary landing as the fuel gauge indication approached zero.

The pilot's texting, which occurred (1) while flying, (2) while the helicopter was being prepared for return to service and (3) during his telephone call to the communication specialist when making his decision to continue the mission, was a self-induced distraction that took his attention away from his primary responsibility to ensure safe flight operations. Further, although there is no evidence that the pilot was texting at the time of the engine failure, his texting while airborne violated the company's cell phone use policy.

Because of restricted sleep the night before the accident, the timing of his operational activities and the nature of the pilot's errors, which were uncharacteristic of his performance, the pilot was experiencing fatigue, which likely degraded his performance.

Because there was no policy requiring that the Air Methods Operational Control Center be notified of abnormal fuel situations, available operationally qualified personnel outside the situation who would likely have recognized the pilot's decision to continue the mission as inappropriate were not consulted.

Although a successful autorotation was possible, the pilot failed to make the flight control inputs necessary to enter an autorotation when the engine lost power, which resulted in a rapid decay in rotor rpm and impact with terrain.

The autorotation training that the pilot received in the Eurocopter AS350 B2 was not representative of an actual engine failure at cruise airspeed and likely contributed to the pilot's failure to execute a successful autorotation.

Without specific guidance regarding the appropriate control inputs for entering an autorotation at cruise airspeeds, the pilots of helicopters with low-inertia rotor systems may not be aware that aft cyclic must be applied when collective is lowered to maintain control of the helicopter and perform a successful autorotation.

Because of the lack of information about the entry phase of autorotations in the FAA's Helicopter Flying Handbook, helicopter pilots may not be aware that there are flight conditions in which immediate and simultaneous control inputs, not only lowering collective, are required to enter an autorotation.

If the pilot had received autorotation training in a simulator rather than in a helicopter, he would have been better prepared and might have effectively responded to the engine failure during the accident flight.

It would seem that paying attention isn't enough. We have to pay attention to the right things at the right times. Getting appropriate rest, sticking to SOPs and maintaining general pessimism about fuel gauges, actual fuel on board and specific range based on ambient conditions all fall into the right-thing category.